NISM Continuing Professional Education

Registration Form

Personal Details
Name of Program: NISM MFD CPE

NISM Registration No.: CL141110037708

Name: Hemant D Bhagat

Address for Communications: Hemvilla
Anandbaug Society
Opp. Powerhouse
City: Billimora

Pin: 396321

Tel: +919824199558

Mobile: +919824199558

Email: hem_298@yahoo.com

PAN No.: AILPB0356M

Gender(M/F):

Date of Birth: 29-Aug-1970

Qualification:

Designation:

Occupation:
Employer(Name of organization):

Certification Details
Name of previous certification module

Previous Certificate Number

Expiry date of previous certificate

AMFI-0261-001825

04-Dec-2014

ARN Details
ARN Number

ARN Expiry Date

35825

03-Dec-2014

CPE Details
CPE Program Name(NISM Series): NISM MFD CPE
CPE Code: CIEL/MFD-908/15-Nov-14/Mumbai

Program Date: 2014-11-15 09:00:00

CPE Centre: Hotel Park View, 37, Lallubhai Park Road, Andheri (W), 400058, Mumbai, Maharashtra, India
CPE Provider: Centre for Investment Education and Learning Private Ltd

Payment Details
DD No./Order No

Amount

Drawee Bank/Branch

DD Date

*The amount is not refundable

I hereby confirm that I am aware of the supporting documents required to be submitted for issuance of CPE certificate by NISM and that NISM
reserves the right to defer/cancel issuance of my CPE certificate at any point of time in case any discrepancies are found in either the fee paid or documents
submitted by me at the CPE venue. I also confirm that I have read the Eligibility Criteria and I am fully aware that if any document/s/information submitted by me
during the registration for the CPE Program is/are found to be incorrect/incomplete/inadequate/invalid, I will neither be entitled to claim refund of the registration
fee paid nor will I be entitled to claim a certificate for the CPE program attended by me.

Date:

Place:

Signature:

NISM Continuing Professional Education

Registration Form

Candidate Category
Grandfathered persons
Attach any of the following :
Copy of proof of completion of 50 years of age on or before 31st May 2010
Letter on letter head of SEBI registerd MF/AMC/RTA for MF and signed by authorised
signatory certifying that the candidate has 10 years of relevant work rxperience in sale
and/or distribution of mutual fund products as on 31st May,2010.

Others
Copy of NISM certificate for specific module
Copy of ARN Card

Kindly enclose following as per sequence:

1. Two photographs (please write your name and PAN no on the back side of the photograph)
2. Copy of previous certificate of NISM
3. Copy of PAN card
4. Demand draft
5. Copy of Age proof (applicable for grandfathered category)
6. Copy of Experience certificate(applicable for grandfathered category)
7. Copy of ARN Card
8. Any other document as may be specified in NISM Circular

______________________________________________________________________________________________________
NISM Contact Details:

National Institute of Securities Markets

6th Floor NISM Bhawan ,plot no 82,Sector 17 Vashi, Navi Mumbai 400 703
Email id: cpe@nism.ac.in | Tel: +91-22-6673 5100-05